- Email: [email protected]
Optimal Dose of Running for Longevity
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
VOL. 65, NO. 5, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.11.022
EDITORIAL COMMENT
Optimal Dose of Running for Longevity Is More Better or Worse?* Duck-chul Lee, PHD,y Carl J. Lavie, MD,z Rajesh Vedanthan, MD, MPHx
A
lthough it is well known that regular exercise
association between jogging and mortality as well
and physical activity (PA) have health bene-
as loss of benefits with higher doses of jogging.
fits, there is still an unanswered question:
Considering the current consensus of a linear dose-
“Is it possible to have too much of a good thing?” In
response relationship between total PA and health,
particular, is high-intensity PA, such as running, a
indicating “the more the PA, the better for health and
healthful activity? The dose-response relationship
longevity,” these findings are intriguing. The good
between running and mortality is still subject to
news is that the mortality benefits of light jogging
debate and controversy.
will encourage more people to jog for health benefits as a “practical, achievable, and sustainable” goal, as
SEE PAGE 411
the authors have stated.
In this issue of the Journal, Schnohr et al. (1) report
However, there are several important study limi-
3 major findings on jogging and all-cause mortality in
tations that should be considered in the interpreta-
1,098 joggers and 3,950 nonjoggers from the Copen-
tion of these interesting results. First, all analyses
hagen City Heart Study. First, jogging even <1 h per
on the association between jogging and mortality
week or 1 time per week is associated with significant
included only 413 sedentary nonjoggers and excluded
mortality risk reduction compared with sedentary
3,537 active nonjoggers who are active in other types
nonjoggers. Second, 1 to 2.4 h of jogging per week,
of PA. Considering other PA (sedentary vs. active)
with a frequency of 2 to 3 times per week, at a slow or
and jogging, we can think of 4 categories of overall
average pace is most favorable as an optimal jogging
PA: 1) sedentary nonjoggers, 2) active nonjoggers, 3)
time, frequency, and speed for reducing mortality.
sedentary joggers, and 4) active joggers. Comparing
Third, higher jogging times ($2.5 h per week), higher
mortality risk in joggers (both sedentary and active)
frequencies (>3 times per week), and faster paces are
with mortality risk in the least active, sedentary
not associated with better survival compared with
nonjoggers without active nonjoggers in the relative
sedentary
nonjoggers,
suggesting
a
U-shaped
risk analyses likely contributed to more significant mortality benefits in joggers. In addition, sedentary nonjoggers were more obese, were nearly 20 years
*Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the yDepartment of Kinesiology, College of Human Sciences, Iowa
older, and had an approximately 5 to 6 times higher prevalence of hypertension and diabetes mellitus compared with joggers in this study, which could increase the risk of mortality irrespective of jogging
State University, Ames, Iowa; zDepartment of Cardiovascular Diseases,
status. Although the authors appropriately adjusted
John Ochsner Heart and Vascular Institute, Ochsner Clinical School–The
for age and diabetes mellitus in their analyses, sta-
University of Queensland School of Medicine, New Orleans, Louisiana;
tistical adjustment would not completely eliminate
and the xZena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York. Dr. Vedanthan
the confounding bias by these large differences,
is supported by the Fogarty International Center of the National In-
potentially leading to overestimation of the mortality
stitutes of Health under Award Number K01 TW 009218-04. The content
benefits of jogging.
is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The au-
Second, Schnohr et al. (1) used a practical but
thors have reported that they have no relationships relevant to the
somewhat arbitrary categorization of doses of jogging.
contents of this paper to disclose.
This categorization resulted in a smaller sample size
Lee et al.
JACC VOL. 65, NO. 5, 2015 FEBRUARY 10, 2015:420–2
Running for Longevity
and lower statistical power for the higher doses of
However, we found mortality benefits of running
jogging, where no mortality benefits were found. For
after adjusting for the total amount of other PA (2).
example, there were only 47 joggers (4%) with the
We also found similar mortality benefits of running
highest jogging time (>4 h per week) and 80 joggers
even after excluding subjects who reported partici-
(9%) with the highest frequency (>3 times per week),
pating in other PA besides running. Thus, it is likely
with only 1 death and 5 deaths in the respective cate-
that running provides mortality benefits independent
gories. However, the adjusted hazard ratios were 0.60
of participating in other types of PA.
(95% confidence interval: 0.08 to 4.36) and 0.71 (95%
Fourth, Schnohr et al. (1) focused on the effects of
confidence interval: 0.29 to 1.75) in each respective
jogging only on all-cause mortality because of the
category, suggesting that significant mortality benefits
limited sample size. However, several studies have
would be possible even with these highest doses of
reported the potential adverse effects of excessive
jogging if these groups had sufficient sample sizes. In
aerobic exercise specifically on cardiovascular dis-
our recent study of running and mortality in 55,137
eases and mortality. In a recent long-distance (90-km)
participants (13,016 runners) with 3,413 deaths (2), we
cross-country ski marathon study of 52,755 partici-
used 5 quintiles so there would be an equal number of
pants (3), the investigators found a higher risk of
participants across different doses of running. We still
developing arrhythmias in those who had completed
found significantly lower risks of mortality even in the
more races. In marathon runners, frequent marathon
highest quintiles of running time ($176 min per week)
running and its required training also appeared to be
and frequency ($6 times per week) compared with
correlated with myocardial damage (4,5). In addition,
nonrunners. Therefore, it is possible that running even
recent evidence suggests that high doses of PA (>30
at high doses may provide mortality benefits compared
miles per week of running and >46 miles per week of
with nonrunners.
walking) in subjects with established coronary heart
Third, Schnohr et al. (1) did not fully take into ac-
disease (CHD) were associated with loss of cardio-
count participation in other types of PA. Jogging is
vascular mortality benefit (6,7). In contrast, there are
one type of PA, and it is possible that nonjoggers and
other studies showing opposite results, with lower
joggers unequally participated in other types of PA.
risks of CHD with higher doses of running (8,9). In our
F I G U R E 1 Death Rates for Major Causes of Death by Weekly Running Time
50 0 45
<60
Death Rate per 10,000 Person-Years
40
60-95 96-150
35
≥151 30 25 20 15 10 5
's er ei m zh Al
In Pn flu eu en m za on an ia d
Di
ab
et
es
l na U In nin ju te rie nt s io
ok e St r
D CH
r ce Ca n
O E the an xce r C d pt VD St C ro HD ke Ch Re ro Di sp nic se ira L as to ow e ry e r
Al
l-c
au
se
0
Causes of Death by Weekly Running Time (min)
Participants were classified into 5 groups: nonrunners and 4 quartiles of weekly running time in minutes. Death rates were adjusted for baseline age, sex, and examination year. CHD ¼ coronary heart disease; CVD ¼ cardiovascular disease.
421
422
Lee et al.
JACC VOL. 65, NO. 5, 2015 FEBRUARY 10, 2015:420–2
Running for Longevity
additional assessments of the effects of running and
CHD mortality. In addition, because self-reported
mortality, we also evaluated cause-specific mortality
doses of running may induce measurement error
(Figure 1). It appears that mortality from all causes
and bias, it would be preferable to use an objective
and cancer was lower in runners compared with
assessment of doses of running in future studies.
nonrunners regardless of dose, although there was
The authors showed that even <1 h per week of
a slight nonsignificant trend for less benefit with
jogging, below the current minimum guidelines of
higher doses of running compared with lower doses
vigorous-intensity aerobic PA ($75 min per week),
of running for all-cause mortality. On the other hand,
may be sufficient for mortality benefits, consistent
CHD mortality appeared to be relatively higher in
with other large studies (2,9,11). Therefore, as a better
those with higher doses of running compared with
option for time efficiency, we should emphasize that
lower doses, with a reverse J-shaped association.
even small amounts of running (<1 h per week) can
Thus, further studies are needed to better evaluate
provide significant mortality benefits for most healthy
this controversial issue. Ideally, these studies will be
but sedentary people. The general consensus of the
well-controlled interventions, because we certainly
data certainly suggests that “more is not better!”
agree that the goal is not to unnecessarily frighten
regarding running and mortality. However, we still
people who wish to participate in more strenuous
need more data to truly determine “is more actually
exercise (10).
worse?” regarding exercise dose and prognosis.
In summary, the study by Schnohr et al. (1) adds to the current body of evidence on the dose-response
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
relationship between running and mortality. Howev-
Duck-chul Lee, Department of Kinesiology, College
er, further exploration is clearly warranted regarding
of Human Sciences, Iowa State University, 251 For-
whether there is an optimal amount of running for
ker Building, Ames, Iowa 50011. E-mail: dclee@
mortality benefits, especially for cardiovascular and
iastate.edu.
REFERENCES 1. Schnohr P, O’Keefe JH, Marott JL, Lange P, Jensen GB. Dose of jogging and long-term mortality: the Copenhagen City Heart Study. J Am Coll
5. Neilan TG, Januzzi JL, Lee-Lewandrowski E, et al. Myocardial injury and ventricular dysfunction related to training levels among nonelite partici-
Cardiol 2015;65:411–9.
pants in the Boston Marathon. Circulation 2006; 114:2325–33.
2. Lee DC, Pate RR, Lavie CJ, Sui X, Church TS, Blair SN. Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol 2014;64:472–81. 3. Andersen K, Farahmand B, Ahlbom A, et al. Risk of arrhythmias in 52 755 long-distance crosscountry skiers: a cohort study. Eur Heart J 2013; 34:3624–31. 4. Mohlenkamp S, Lehmann N, Breuckmann F, et al. Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur Heart J 2008;29:1903–10.
6. Williams PT, Thompson PD. Increased cardiovascular disease mortality associated with excessive exercise in heart attack survivors. Mayo Clin Proc 2014;89:1187–94. 7. O’Keefe JH, Franklin B, Lavie CJ. Exercising for health and longevity vs peak performance: different regimens for different goals. Mayo Clin Proc 2014;89:1171–5. 8. Williams PT. Reductions in incident coronary heart disease risk above guideline physical activity levels in men. Atherosclerosis 2010;209: 524–7.
9. Chomistek AK, Cook NR, Flint AJ, Rimm EB. Vigorous-intensity leisure-time physical activity and risk of major chronic disease in men. Med Sci Sports Exerc 2012;44:1898–905. 10. Levine BD. Can intensive exercise harm the heart? The benefits of competitive endurance training for cardiovascular structure and function. Circulation 2014;130:987–91. 11. Wen CP, Wai JP, Tsai MK, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 2011;378:1244–53.
KEY WORDS cardiovascular disease, dose response, mortality, physical activity, running
VOL. 65, NO. 5, 2015
ª 2015 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION
ISSN 0735-1097/$36.00
PUBLISHED BY ELSEVIER INC.
http://dx.doi.org/10.1016/j.jacc.2014.11.022
EDITORIAL COMMENT
Optimal Dose of Running for Longevity Is More Better or Worse?* Duck-chul Lee, PHD,y Carl J. Lavie, MD,z Rajesh Vedanthan, MD, MPHx
A
lthough it is well known that regular exercise
association between jogging and mortality as well
and physical activity (PA) have health bene-
as loss of benefits with higher doses of jogging.
fits, there is still an unanswered question:
Considering the current consensus of a linear dose-
“Is it possible to have too much of a good thing?” In
response relationship between total PA and health,
particular, is high-intensity PA, such as running, a
indicating “the more the PA, the better for health and
healthful activity? The dose-response relationship
longevity,” these findings are intriguing. The good
between running and mortality is still subject to
news is that the mortality benefits of light jogging
debate and controversy.
will encourage more people to jog for health benefits as a “practical, achievable, and sustainable” goal, as
SEE PAGE 411
the authors have stated.
In this issue of the Journal, Schnohr et al. (1) report
However, there are several important study limi-
3 major findings on jogging and all-cause mortality in
tations that should be considered in the interpreta-
1,098 joggers and 3,950 nonjoggers from the Copen-
tion of these interesting results. First, all analyses
hagen City Heart Study. First, jogging even <1 h per
on the association between jogging and mortality
week or 1 time per week is associated with significant
included only 413 sedentary nonjoggers and excluded
mortality risk reduction compared with sedentary
3,537 active nonjoggers who are active in other types
nonjoggers. Second, 1 to 2.4 h of jogging per week,
of PA. Considering other PA (sedentary vs. active)
with a frequency of 2 to 3 times per week, at a slow or
and jogging, we can think of 4 categories of overall
average pace is most favorable as an optimal jogging
PA: 1) sedentary nonjoggers, 2) active nonjoggers, 3)
time, frequency, and speed for reducing mortality.
sedentary joggers, and 4) active joggers. Comparing
Third, higher jogging times ($2.5 h per week), higher
mortality risk in joggers (both sedentary and active)
frequencies (>3 times per week), and faster paces are
with mortality risk in the least active, sedentary
not associated with better survival compared with
nonjoggers without active nonjoggers in the relative
sedentary
nonjoggers,
suggesting
a
U-shaped
risk analyses likely contributed to more significant mortality benefits in joggers. In addition, sedentary nonjoggers were more obese, were nearly 20 years
*Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. From the yDepartment of Kinesiology, College of Human Sciences, Iowa
older, and had an approximately 5 to 6 times higher prevalence of hypertension and diabetes mellitus compared with joggers in this study, which could increase the risk of mortality irrespective of jogging
State University, Ames, Iowa; zDepartment of Cardiovascular Diseases,
status. Although the authors appropriately adjusted
John Ochsner Heart and Vascular Institute, Ochsner Clinical School–The
for age and diabetes mellitus in their analyses, sta-
University of Queensland School of Medicine, New Orleans, Louisiana;
tistical adjustment would not completely eliminate
and the xZena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York. Dr. Vedanthan
the confounding bias by these large differences,
is supported by the Fogarty International Center of the National In-
potentially leading to overestimation of the mortality
stitutes of Health under Award Number K01 TW 009218-04. The content
benefits of jogging.
is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The au-
Second, Schnohr et al. (1) used a practical but
thors have reported that they have no relationships relevant to the
somewhat arbitrary categorization of doses of jogging.
contents of this paper to disclose.
This categorization resulted in a smaller sample size
Lee et al.
JACC VOL. 65, NO. 5, 2015 FEBRUARY 10, 2015:420–2
Running for Longevity
and lower statistical power for the higher doses of
However, we found mortality benefits of running
jogging, where no mortality benefits were found. For
after adjusting for the total amount of other PA (2).
example, there were only 47 joggers (4%) with the
We also found similar mortality benefits of running
highest jogging time (>4 h per week) and 80 joggers
even after excluding subjects who reported partici-
(9%) with the highest frequency (>3 times per week),
pating in other PA besides running. Thus, it is likely
with only 1 death and 5 deaths in the respective cate-
that running provides mortality benefits independent
gories. However, the adjusted hazard ratios were 0.60
of participating in other types of PA.
(95% confidence interval: 0.08 to 4.36) and 0.71 (95%
Fourth, Schnohr et al. (1) focused on the effects of
confidence interval: 0.29 to 1.75) in each respective
jogging only on all-cause mortality because of the
category, suggesting that significant mortality benefits
limited sample size. However, several studies have
would be possible even with these highest doses of
reported the potential adverse effects of excessive
jogging if these groups had sufficient sample sizes. In
aerobic exercise specifically on cardiovascular dis-
our recent study of running and mortality in 55,137
eases and mortality. In a recent long-distance (90-km)
participants (13,016 runners) with 3,413 deaths (2), we
cross-country ski marathon study of 52,755 partici-
used 5 quintiles so there would be an equal number of
pants (3), the investigators found a higher risk of
participants across different doses of running. We still
developing arrhythmias in those who had completed
found significantly lower risks of mortality even in the
more races. In marathon runners, frequent marathon
highest quintiles of running time ($176 min per week)
running and its required training also appeared to be
and frequency ($6 times per week) compared with
correlated with myocardial damage (4,5). In addition,
nonrunners. Therefore, it is possible that running even
recent evidence suggests that high doses of PA (>30
at high doses may provide mortality benefits compared
miles per week of running and >46 miles per week of
with nonrunners.
walking) in subjects with established coronary heart
Third, Schnohr et al. (1) did not fully take into ac-
disease (CHD) were associated with loss of cardio-
count participation in other types of PA. Jogging is
vascular mortality benefit (6,7). In contrast, there are
one type of PA, and it is possible that nonjoggers and
other studies showing opposite results, with lower
joggers unequally participated in other types of PA.
risks of CHD with higher doses of running (8,9). In our
F I G U R E 1 Death Rates for Major Causes of Death by Weekly Running Time
50 0 45
<60
Death Rate per 10,000 Person-Years
40
60-95 96-150
35
≥151 30 25 20 15 10 5
's er ei m zh Al
In Pn flu eu en m za on an ia d
Di
ab
et
es
l na U In nin ju te rie nt s io
ok e St r
D CH
r ce Ca n
O E the an xce r C d pt VD St C ro HD ke Ch Re ro Di sp nic se ira L as to ow e ry e r
Al
l-c
au
se
0
Causes of Death by Weekly Running Time (min)
Participants were classified into 5 groups: nonrunners and 4 quartiles of weekly running time in minutes. Death rates were adjusted for baseline age, sex, and examination year. CHD ¼ coronary heart disease; CVD ¼ cardiovascular disease.
421
422
Lee et al.
JACC VOL. 65, NO. 5, 2015 FEBRUARY 10, 2015:420–2
Running for Longevity
additional assessments of the effects of running and
CHD mortality. In addition, because self-reported
mortality, we also evaluated cause-specific mortality
doses of running may induce measurement error
(Figure 1). It appears that mortality from all causes
and bias, it would be preferable to use an objective
and cancer was lower in runners compared with
assessment of doses of running in future studies.
nonrunners regardless of dose, although there was
The authors showed that even <1 h per week of
a slight nonsignificant trend for less benefit with
jogging, below the current minimum guidelines of
higher doses of running compared with lower doses
vigorous-intensity aerobic PA ($75 min per week),
of running for all-cause mortality. On the other hand,
may be sufficient for mortality benefits, consistent
CHD mortality appeared to be relatively higher in
with other large studies (2,9,11). Therefore, as a better
those with higher doses of running compared with
option for time efficiency, we should emphasize that
lower doses, with a reverse J-shaped association.
even small amounts of running (<1 h per week) can
Thus, further studies are needed to better evaluate
provide significant mortality benefits for most healthy
this controversial issue. Ideally, these studies will be
but sedentary people. The general consensus of the
well-controlled interventions, because we certainly
data certainly suggests that “more is not better!”
agree that the goal is not to unnecessarily frighten
regarding running and mortality. However, we still
people who wish to participate in more strenuous
need more data to truly determine “is more actually
exercise (10).
worse?” regarding exercise dose and prognosis.
In summary, the study by Schnohr et al. (1) adds to the current body of evidence on the dose-response
REPRINT REQUESTS AND CORRESPONDENCE: Dr.
relationship between running and mortality. Howev-
Duck-chul Lee, Department of Kinesiology, College
er, further exploration is clearly warranted regarding
of Human Sciences, Iowa State University, 251 For-
whether there is an optimal amount of running for
ker Building, Ames, Iowa 50011. E-mail: dclee@
mortality benefits, especially for cardiovascular and
iastate.edu.
REFERENCES 1. Schnohr P, O’Keefe JH, Marott JL, Lange P, Jensen GB. Dose of jogging and long-term mortality: the Copenhagen City Heart Study. J Am Coll
5. Neilan TG, Januzzi JL, Lee-Lewandrowski E, et al. Myocardial injury and ventricular dysfunction related to training levels among nonelite partici-
Cardiol 2015;65:411–9.
pants in the Boston Marathon. Circulation 2006; 114:2325–33.
2. Lee DC, Pate RR, Lavie CJ, Sui X, Church TS, Blair SN. Leisure-time running reduces all-cause and cardiovascular mortality risk. J Am Coll Cardiol 2014;64:472–81. 3. Andersen K, Farahmand B, Ahlbom A, et al. Risk of arrhythmias in 52 755 long-distance crosscountry skiers: a cohort study. Eur Heart J 2013; 34:3624–31. 4. Mohlenkamp S, Lehmann N, Breuckmann F, et al. Running: the risk of coronary events: prevalence and prognostic relevance of coronary atherosclerosis in marathon runners. Eur Heart J 2008;29:1903–10.
6. Williams PT, Thompson PD. Increased cardiovascular disease mortality associated with excessive exercise in heart attack survivors. Mayo Clin Proc 2014;89:1187–94. 7. O’Keefe JH, Franklin B, Lavie CJ. Exercising for health and longevity vs peak performance: different regimens for different goals. Mayo Clin Proc 2014;89:1171–5. 8. Williams PT. Reductions in incident coronary heart disease risk above guideline physical activity levels in men. Atherosclerosis 2010;209: 524–7.
9. Chomistek AK, Cook NR, Flint AJ, Rimm EB. Vigorous-intensity leisure-time physical activity and risk of major chronic disease in men. Med Sci Sports Exerc 2012;44:1898–905. 10. Levine BD. Can intensive exercise harm the heart? The benefits of competitive endurance training for cardiovascular structure and function. Circulation 2014;130:987–91. 11. Wen CP, Wai JP, Tsai MK, et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 2011;378:1244–53.
KEY WORDS cardiovascular disease, dose response, mortality, physical activity, running